<div style="display:block;background-color:#FFF">
  <a href="#" onclick ="$('#tracking_page').dialog('close')" data-role="button" data-inline="true" data-icon="back">Back</a>
  <a href="#mainpage" onclick ="changeTracking()" rel="external" data-role="button" data-inline="true" data-theme="b" data-icon="check">Submit</a>

<br/>


<label for="service" class="ui-input-text">Service:</label>
<select name="service" id="service" data-native-menu='false'>
<option value="Not"> -- Not Selected -- </option>
<option value="Ottawa">Family Medicine Clinic</option>
<option value="Toronto">Emergency Care</option>
<option value="Montreal">Other Rotation...</option>
</select>

<label for="location" class="ui-input-text">Location:</label>
<select name="location" id="location" data-native-menu='false'>
<option value="Not"> -- Not Selected -- </option>
<option value="Ottawa">Ottawa Hospital</option>
<option value="Toronto">Toronto Med</option>
<option value="Montreal">Long Term Care Facility</option>
</select>

<label for="supervising" class="ui-input-text">Supervising Physician:</label>
<select name="supervising" id="supervising" data-native-menu='false'>
<option value="Not"> -- Not Selected -- </option>
<option value="SeanD" >Sean Dube</option>
<option value="ShawnD">Shawn Dexter</option>
<option value="Steve">Steve Dupois</option>
<option value="Eric">Eric Walton</option>
</select>

<label for="date">Date:</label>
<input name="date" id="date" type="text" class="date">

<br/>
  <a href="#" onclick ="$('#tracking_page').dialog('close')" data-role="button" data-inline="true" data-icon="back">Back</a>
  <a href="#mainpage" onclick ="changeTracking()" rel="external" data-role="button" data-inline="true" data-theme="b" data-icon="check">Submit</a>


</div>